This questionnaire was designed to help understand your feelings, desires and

needs for English and to help you achieve your goals.

Please answer the questions as honestly as possible with as much detail as possible
as well.

1. My feelings towards English

Answer the following questions about your past and present feelings towards
English.

I usually feel ~ when I speak English because…

I usually feel ~ when I study English because…

I felt ~ when I started learning English because…

I hope to feel ~ about English because…

Example:
I usually feel nervous when I speak English because I think I make so many
mistakes and I speak very slowly. Sometimes I think people think I’m not smart
when I speak English!
2. History of English
Please briefly explain your history with English.

This can include when you started to study, how you have learned, what resources
you use to study and when you have used English in your life.

Example: 
I first started to learn English in high school about 7 years ago and a little bit in
university but I haven’t spoken it too much since then. I only spoke English when I
traveled outside of my home country on vacation, which was only one time when I
went to the United States. Now I have a new job where I have a conference call in
English every month.
3. Present challenges
Please write about any challenges that you may have with English.
These could be about your abilities, your feelings or anything you feel that is
holding you back.

What do you want or need to improve?

I presently have challenges with…

Example:
I presently have challenges with listening to people from foreign countries
speaking English like India, China and other places. Their accents are difficult for
me to understand. I also struggle with staying motivated because I get discouraged
easily.
4. Present strengths
Please write about what you believe are your strengths in English. These could be
about your abilities, your attitudes or anything you feel that helps you learn
English.

My present strengths include…

Example:
My present strengths include being optimistic and interested in learning. I am
also good at reading quickly since I watch many TV shows with subtitles in
English.
5. Specific goals and deadlines
Please write down three goals you hope to achieve with your English and a
deadline for each one of them.

Be sure to make these goals specific, achievable and measurable.

A specific goal will have details that make it clear what exactly you want to do.
An achievable goal is a goal that is very realistic to complete, given the amount of
time and effort required.
A measurable goal is one with a specific deadline and achievement. This way you
will know exactly when you have completed your goal!
Examples:
1. I want to watch an entire movie in English without subtitles and understand it
by the end of next month.
2. I want to make fewer than 5 mistakes at my next presentation by the end of next
week.
3. I want to study for 10 minutes every morning (total of 300 minutes) by this time
next month.
6. Definitions
Write your own definitions to these words or expressions. Try to write what the
words mean to you. Do not use a dictionary to define them.

Fluent:

Good English Speaker:

Proficient:
Conversational English:

Speaking Well:

Advanced Level English:

Intermediate Level English:

7. S.L.R.W. Importance Scale

Write down how important each category is to you and your English on a scale
from 0-100 but make sure that all the numbers add up to 100. Then below, write
down why you wrote down those numbers.

(S) Speaking _________

(L) Listening _________
(R) Reading _________
(W) Writing _________

Examples:
(S) Speaking 50%
(L) Listening 30%
(R) Reading 15%
(W) Writing 5%
I want to learn English for traveling and meeting people in different places so it’s
important for me to practice speaking and listening. Reading may be important for
understanding signs and notices. I don’t imagine I would use writing very often.
8. I will be content when… because…
Fill in the blanks and write what it will take to make you content and why that will
make you content. You can write anything you would like.

I will be content when ~ because…

Examples:
I will be content when I no longer feel nervous or anxious when I speak
English because it always makes me feel bad and I don’t want to feel bad
anymore.
I will be content when I can express myself in English without thinking of the
words I want to say or pausing because it’s my dream to speak English as good as
I speak my own language.